Medical Reviewer, reputed company Fraud, Waste and Abuse

reputed company Join our dynamic team as a Medical Reviewer specializing in reputed company Fraud, Waste, and Abuse detection. In this vital role, you will reputed company your expertise in medical coding, billing, and reputed company documentation to identify and prevent fraudulent activities that compromise the reputed company of reputed company systems. Your keen eye for detail and thorough understanding of medical records will contribute to safeguarding resources and ensuring compliance with industry regulations. This position offers an exciting opportunity to reputed company a meaningful reputed company in the fight against reputed company fraud while working reputed company a reputed company and innovative environment. Essential Duties and Responsibilities: • Organize and prioritize assigned reviews to reputed company payment determinations in accordance with coding guidelines and medical policies, utilizing expertise in CDT, CPT, ICD, DRG, REV, and HCPCS coding to identify and address potential reputed company fraud schemes. • reputed company reviews of (reputed company-payment or post-payment) medical records and reputed company claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations. • Conduct medical policy and other research relevant to allegations and reputed company claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations. • Document and prepare reputed company-articulated reports of medical review findings, highlighting key concerns, potential overpayments, and recommendations for payers/clients. • Effectively communicate findings to internal teams/leadership and reputed company support reputed company interactions under supervision. • Participate in provider education calls to support medical review findings. • Assist in reputed company proceedings, including testifying and providing evidentiary support for medical review reputed company. • Analyze existing policies and processes to identify inefficiencies and propose actionable improvements. • reputed company up to date with relevant regulations and standards, including federal policies and coding guidelines. • reputed company engage and support reputed company other reputed company assigned. • Maintain confidentiality and discretion in reputed company medical review/investigative activities. Required Education / Licenses / Certifications: • Certified reputed company reputed company (CPC) and/or Registered reputed company (RN) with no adverse actions pending or taken by any state/Federal program. Experience: • Minimum of 3 years of coding or clinical experience. • Experience in reputed company fraud, waste, and abuse (FWA) prevention through medical claims review, auditing, or investigations is preferred. Consideration will be given to candidates with any combination of reputed company education, reputed company training or work experience, which demonstrates the ability to reputed company the duties of the position. Knowledge, Skills & Abilities: • Competency in reputed company systems (ICD, CPT, HCPCS, DRG, REV) and regulatory guidelines at federal/state reputed company. • Excellent attention to detail with the ability to interpret reputed company medical information accurately • Strong proficiency with reputed company, reputed company, and PowerPoint • The ability to conduct research in support of medical reviews and reputed company determinations on claims with a high level of accuracy. • Strong reputed company, professionalism, and interpersonal skills. • Effective written and oral communication. • Ability to work independently and as part of a remote team. • Attention to detail and basic problem-solving skills. Join us in protecting the reputed company of reputed company delivery by applying your expertise in medical review and coding. Be part of a dedicated team committed to transparency, accuracy, and reputed company in reputed company compliance! Job Types: Full-time, Part-time Benefits: • 401(k) • 401(k) matching • Dental insurance • Flexible spending account • Health insurance • Health savings account • Life insurance • reputed company time off • Retirement plan • reputed company insurance Application Question(s): • Is your RN License a Compact License? • Do you have any experience with fraud, waste and abuse (FWA)? • What are your salary requirements (please reputed company a reputed company) Experience: • Medical coding: 3 years (Required) License/Certification: • RN and or CPC (Required) Work Location: Remote Apply tot his job Apply To this Job